Patient Assistance Program application

About you

First name (legal name)

Last name

Date of birth

Phone

Home address

City

State

ZIP code

Email

How should we contact you?

Telephone Email Other

How?

Were you referred to us by a doctor or other health care provider?

Yes No

Referring provider: name and contact information

The patient

Who needs help with the medical costs?

Me Someone else (a child, a spouse, a parent…)

Patient's full name

Patient's date of birth

Your relationship to the patient

Household and income

Number of people in your household (with you)

The other people in your household (who live with you and share expenses):

Name	Age	Relationship to you	Dependent

Your yearly gross income ($)

Total yearly gross household income ($)

Sources of household income

Other income

We compare household income with the Federal Poverty Guidelines published each year by the U.S. Department of Health and Human Services. Households at or below 300% of the guidelines ordinarily meet our income standard; between 300% and 400% may qualify because of other financial hardship; above 400% may be considered in exceptional circumstances involving substantial documented hardship.

Financial hardship

If your household income is above 300% of the guidelines, or your situation isn't reflected by your income, describe what significantly affects your ability to pay: substantial medical expenses, loss or reduction of income, disability-related expenses, necessary caregiving expenses, unusually high household expenses, or other significant financial obligations.

Available resources

Any significant financial resources reasonably available to you that could be used toward the medical expenses.

Medical condition and need for assistance

We do not need your complete medical history. Please give only information related to the medical expenses you are asking help with.

Has a doctor diagnosed the condition?

Kind of condition

How serious, as your doctor described it?

Approximate date diagnosed or treatment began

Briefly describe the medical condition, illness, injury, disability, or other health-related circumstance

Briefly describe the treatment, procedure, medication, therapy, equipment, or other care you have received or need

When is (was) the treatment?

What happens if you don't get help?

Current status (tick all that apply)

Treatment has been completed. Treatment is currently ongoing. Additional treatment is anticipated. Treatment has not yet begun. The condition requires ongoing medication or medical services. The condition substantially affects activities of daily living. Delay in treatment may materially affect my health. Other

Other

Medical urgency and expected benefit (if relevant)

Why payment is particularly important or time-sensitive: whether the treatment is expected to prevent deterioration, relieve significant symptoms or suffering, improve functioning, treat or cure the condition, or otherwise bring a significant medical benefit.

A letter from your doctor or other licensed health care provider describing the diagnosis and treatment plan is required. You will upload it in your account.

Medical expenses and debt

Type of assistance requested (tick all that apply)

Treatment not yet paid (a cost estimate or invoice) Travel and lodging to receive treatment (appointment confirmation and estimated travel costs) Existing medical bill or debt (the itemized bill)

The medical expenses or debts you are asking help with:

Provider / creditor	Type of expense	Original amount ($)	Current balance ($)

Medical debt you already owe ($, 0 if none)

Amount of assistance you are asking us for ($)

The amount paid, if any, may be less than the amount requested and depends on available Program funds.

Your payment priority (optional)

If you have more than one expense, the order in which you would prefer us to apply any approved grant. We will try to honor it; every expense is still subject to verification and approval.

First priority

Second priority

Third priority

Insurance and other sources of payment

Do you currently have health insurance?

Yes No

Insurance company

Policy / member number

Has the expense been submitted to your insurer?

Yes No Not applicable

Has the insurer finished processing the claim?

Yes No

Have you applied for charity care, financial assistance, or a hardship reduction from the hospital or provider?

Yes No Not available I don't know

What was the result?

Does insurance or a public program cover these costs?

Have you received, applied for, or do you expect payment or assistance for the same medical expenses from any of these?

Governmental benefits Another charitable organization Crowdfunding or community fundraising Legal settlement Insurance settlement or reimbursement Employer assistance Provider discount or debt forgiveness Other None

Other source

If applicable: which source

Amount received ($)

Amount expected ($)

Relationship to Wish Big Foundation

Are you, or is the patient, a director, officer, employee, substantial contributor, grant reviewer, or family member of any of these persons, or in any way affiliated with Wish Big Foundation, Inc.?

Yes No

Please describe the relationship

Disclosure of a relationship does not necessarily result in automatic disqualification. The Corporation will evaluate any potential conflict in accordance with its conflict-of-interest policies and applicable law, and any interested person shall not participate in the review or approval of the application.

Documents we will ask for

If we can take your application forward, you will upload these in your private account (you don't need them now):

Proof of identity (government-issued photo ID)
Proof of household income: your most recent federal income tax return, 2 recent pay stubs, or a benefits award letter
Letter from your doctor or other licensed health care provider stating the diagnosis and treatment plan
Insurance information, or a denial or Explanation of Benefits showing what insurance does not cover
Signed Authorization for Disclosure of Medical Billing Information (you sign it online in your account)
Depending on the help: for treatment, a cost estimate or invoice; for travel, the appointment confirmation and travel costs; for an existing medical bill, the itemized bill

We do not ordinarily require complete medical records: please don't send medical information unrelated to the help requested.

Applicant certification

By signing below, I represent and certify that:

The information and documentation provided in this application are true, accurate, and complete to the best of my knowledge;
The medical expenses or medical debt for which I am requesting assistance are genuine obligations incurred by or on behalf of me or another beneficiary identified and approved in this application;
I have disclosed applicable insurance coverage and other sources of payment that may pay, reimburse, reduce, or otherwise satisfy the medical expenses for which assistance is requested;
I have disclosed any material financial assistance, insurance proceeds, governmental benefits, hospital financial assistance, charitable assistance, settlements, or other payments already received or reasonably expected to be received with respect to the expenses for which assistance is requested;
I will promptly notify the Corporation of any material change in my financial circumstances, medical expenses, insurance coverage, outstanding balances, or other information that may affect my eligibility or the amount of assistance before payment of an approved Grant;
I have not knowingly submitted, and will not knowingly submit, the same medical expense for duplicative payment or reimbursement from the Corporation and another source;
I have not knowingly omitted, concealed, or misrepresented information that would materially affect the Corporation's determination of eligibility or the amount of assistance; and
I understand that submitting this application does not guarantee assistance, and that approval of my application does not guarantee payment. Any payment will be made only if, and to the extent that, Program funds are available or become available, and I may receive partial payment or no payment. Any award is subject to the Corporation's eligibility requirements, verification procedures, available funding, and Patient Assistance Program policies.
I authorize the Corporation to use the information contained in this application for purposes of evaluating and administering my request for charitable assistance. I understand that additional authorization may be required before a health care provider may disclose protected medical or billing information directly to the Corporation.

Nature of assistance: the Corporation is not a health care provider

Please read each statement and tick the box to confirm that you understand and agree.

Not a health care provider. I understand that Wish Big Foundation, Inc. (the "Corporation") is a charitable organization that provides financial assistance only. It is not a hospital, clinic, physician, medical group, pharmacy, insurer, or other health care provider, and it does not practice medicine or any other health care profession. No diagnosis, treatment, or medical advice. I understand that the Corporation does not diagnose, treat, prevent, or cure any illness, injury, or condition. It does not provide medical, nursing, psychological, pharmaceutical, or other clinical advice, opinions, referrals, or recommendations. Nothing communicated by the Corporation, its directors, officers, staff, or volunteers is medical advice, and I will not rely on it as such. No effect on my medical care. I understand that the Corporation does not direct, approve, alter, modify, interrupt, or interfere with my current, past, or future diagnosis, treatment plan, prescriptions, procedures, or course of care. All decisions about my health care remain solely between me and my licensed health care providers. No judgment of medical necessity. I understand that the Corporation's review of my application is an administrative and financial review only. A decision to approve, partially approve, defer, or deny assistance is not a determination of, and does not reflect any opinion on, the medical necessity, appropriateness, quality, or outcome of any diagnosis, treatment, or service. I will not delay or forgo care. I understand that I should not delay, change, or forgo any recommended medical care, or stop following my treatment plan, while my application is pending or because of any decision the Corporation makes. In a medical emergency, I will call 911 or go to the nearest emergency room. No provider–patient relationship. I understand that applying to, communicating with, or receiving assistance from the Corporation does not create a physician–patient, provider–patient, or other health care relationship between me and the Corporation. Billing negotiations only. I understand that when the Corporation communicates with hospitals, physicians, medical groups, billing companies, or other entities on my behalf, it does so only about charges, balances, and payment arrangements. It does not discuss, influence, or seek to change my diagnosis or treatment. No responsibility for care received. I understand that any assistance is paid directly to the provider or billing entity. That payment is not an endorsement of the provider or the services, and the Corporation is not responsible for the quality, safety, timeliness, or results of any care I receive. General resources only. I understand that any information the Corporation shares about outside programs, grants, or organizations is for general informational purposes only. I am responsible for contacting and applying to any such programs, and the Corporation does not guarantee their availability or results.

Signatures

By signing below, I confirm that I have read and understand this entire application, including the Corporation's Nature of Assistance statement and the Applicant Certification. I agree to all of the statements I have ticked and certified above.

Applicant: type your full name to sign

Patient (if different from the applicant): the patient types their full name to sign

Parent, legal guardian, or authorized representative (complete only if the patient is under 18, or if someone is signing on the patient's behalf)

Representative: type your full name to sign

Relationship to the patient

Other relationship

We may ask for documentation of your authority (for example guardianship papers or a power of attorney).

I agree that typing my name above, or signing electronically, has the same legal effect as a handwritten signature.